Medication prescribing patterns for patients with bipolar I disorder in hospital settings: adherence to published practice guidelines.

OBJECTIVE: The purposes of this paper were to examine the medication prescribing patterns for bipolar I disorder in hospital settings and to compare them to recently published expert consensus guidelines for medication treatment of bipolar disorder. METHODS: Data were obtained from the 1996-2000 CQI+SM Outcomes Measurement System, on patients age 18 or older admitted to psychiatric inpatient units from over 100 medical-surgical hospitals. A total of 1864 patients with a primary discharge diagnosis of bipolar I or II disorder were identified from a large cohort of hospitalized patients. Patient characteristics were assessed at hospital admission and medication usage, at discharge. The medication analysis focused on the 1471 individuals with bipolar I mania or bipolar I depression (with or without psychotic features), representing 54% and 25% of admitted bipolar patients, respectively. RESULTS: At admission, the typical bipolar patient (mean age 57) had experienced a relatively severe and chronic course of illness. The array of psychotropic agents used was broad, with no single prescribing pattern predominant. Only one in three bipolar I (manic or depressed) patients with psychotic features was discharged on medications recommended by expert guidelines as preferred or alternate recommended treatment. Absent psychotic features, this dropped to one in six patients. Surprising was the relatively high use of antidepressants for patients with mania, particularly those without psychotic symptoms. CONCLUSIONS: Results suggest that a substantial proportion of patients with bipolar I disorder are discharged from hospitals on medications not generally recommended by current practice guidelines.

Stability and change of DSM-III-R personality disorder dimensions in adolescents followed up 2 years after psychiatric hospitalization.

We examined the stability of DSM-III-R personality disorder dimensions in a clinical sample of adolescents. Sixty adolescent inpatients were reliably assessed with the Personality Disorder Examination (PDE) soon after admission to the Yale Psychiatric Institute, and were independently reassessed with the same instrument 2 years following discharge. PDE symptom ratings were summed to create dimensional scores for each personality disorder. To assess the dimensional stability of personality disorders, intraclass correlation coefficients (ICCs) were computed. To assess the magnitude of the difference between baseline and follow-up scores, paired t tests were used. Significant ICCs were observed for histrionic, narcissistic, dependent, obsessive-compulsive, and passive-aggressive personality disorders. Compared to baseline, dimensional scores for most personality disorders were significantly lower at follow-up-and none was significantly higher. Diagnostic stability is a key defining feature of personality disorders. We observed low-to-moderate stability for dimensional measures of personality dysfunction in adolescents-suggesting that previous reports of modest personality disorder stability in this age group cannot be attributed solely to limitations of the categorical approach to such pathology. Alternatively, our findings may be viewed as consistent with reports in the adult literature that personality disorders may improve over time, and can potentially benefit from treatment.

Antipsychotic treatment of behavioral and psychological symptoms of dementia in geropsychiatric inpatients.

Behavioral/psychological symptoms of dementia (BPSD) affect caregiver burden and transition from home to hospital or long-term care. The authors examined change in BPSD for dementia patients (from hospital admission to discharge) who were prescribed haloperidol (n= 289), olanzapine (n=209), or risperidone (n=500). Olanzapine was associated with significantly greater overall improvement in BPSD (based on the Psychogeriatric Dependency Rating Scale total score) than risperidone or haloperidol. Olanzapine was significantly superior on measures of active-, verbal-, and passive-aggression and delusions/hallucinations to risperidone or haloperidol, and, on manipulative behavior and noisiness, to risperidone. Results support the effectiveness of olanzapine in improving several BPSD in hospitalized dementia patients.

Applicability of personality disorder criteria in late adolescence: internal consistency and criterion overlap 2 years after psychiatric hospitalization.

We examined internal consistency and criterion overlap of DSM-III-R personality disorder criteria in late adolescence, 2 years after psychiatric hospitalization. A total of 60 adolescents were assessed with the Personality Disorder Examination. Within-category cohesiveness (internal consistency) was evaluated by coefficient alpha and mean intercriterion correlation (MIC). Between-category criterion overlap was evaluated by examining intercategory mean intercriterion correlations (ICMIC) between all pairs of disorders. Internal consistency was low, with alpha less than .70 for all except borderline and dependent personality disorders. For most disorders, MIC values were higher than ICMIC values. Our findings suggest that personality disorder criteria sets have limited internal consistency in older adolescents. Although the criteria for most personality disorders correlate better with each other than with the criteria for other personality disorders, suggesting some degree of discriminant validity, comparison of these results with a similar analysis performed shortly after hospital admission raises questions about personality disorder construct validity during adolescence.

Comorbidity of borderline personality disorder with other personality disorders in hospitalized adolescents and adults.

OBJECTIVE: The authors examined the comorbidity of borderline personality disorder with other personality disorders in a series of consecutively admitted adolescents. For comparison, the comorbidity of borderline personality disorder with other personality disorders was also examined in a series of adults consecutively admitted to the same hospital during the same period. METHOD: A total of 138 adolescents and 117 adults were reliably assessed with the Personality Disorder Examination, a semistructured diagnostic interview for DSM-III-R personality disorders. Sixty-eight adolescents and 50 adults met the diagnostic criteria for borderline personality disorder. The co-occurrence of other personality disorders in the group of subjects with borderline personality disorder was statistically compared to that in the group without borderline personality disorder, for adolescents and adults separately. RESULTS: For the adults, Bonferroni-corrected chi-square analysis revealed significant diagnostic co-occurrence with borderline personality disorder for antisocial personality disorder only. For the adolescents, borderline personality disorder showed significant co-occurrence with schizotypal and passive-aggressive personality disorders. CONCLUSIONS: In the adults, borderline personality disorder was significantly comorbid only with another cluster B disorder. The adolescents, by comparison, displayed a broader pattern of comorbidity of borderline personality disorder, encompassing aspects of clusters A and C. These results suggest that the borderline personality disorder diagnosis may represent a more diffuse range of psychopathology in adolescents than in adults.

Effects of alcohol consumption on the treatment of depression among elderly patients.

The authors examined the effects of alcohol use on the short-term and 3-4-month treatment outcomes of patients with late-life depression. Patients (N=2,666) were assessed for symptoms of depression, alcohol use, and disability during an initial inpatient hospitalization and then 3-4 months postdischarge. Contrary to our hypothesis that alcohol consumption imparted a significant additive detriment to treatment outcome in patients already suffering from major depression, the results suggest that treatment was effective even in those with concomitant use of alcohol. Moreover, there appeared to be an added benefit when even modest alcohol consumption was decreased among elderly patients suffering from depression.

Change in disability follows inpatient treatment for late life depression.

OBJECTIVES: The objective of this study was to examine the relationship between functional disability and improvement in late life depression after acute inpatient treatment. DESIGN: The study was a longitudinal assessment of depression and disability. Patients were assessed during an initial inpatient hospitalization and then 3 months postdischarge. SETTING: All patients were evaluated initially after admission to one of 71 inpatient psychiatric treatment facilities. PARTICIPANTS: The study comprised of 2572 patients older than age 60 who were relatively cognitively intact and experiencing significant depressive symptoms. MEASUREMENTS: Depressive symptoms were measured using the Geriatric Depression Scale. Disability was measured using the Instrumental Activities of Daily Living Scale and the Medical Outcomes SF-36. RESULTS: Depressive symptoms improved in the majority of patients. Moreover, improvement in depressive symptomatology was significantly related to improvement in instrumental activities of daily living (IADLs) and to health-related quality of life as measured by the SF-36. This relationship was strongest among those who initially presented with some disability in IADLs. CONCLUSIONS: This work underscores further the disabling nature of depression. Moreover, findings from this study suggest that treatment focused on depression can lead to significant improvements in both depressive symptoms and functional abilities. However, the results also suggest that the relationship between depression and disability is complex and that the effect of treating depression is not the only factor in the reversal of disability.

Concurrent and predictive validity of the personality disorder diagnosis in adolescent inpatients.

OBJECTIVE: The authors investigated the concurrent and predictive validity of the DSM-III-R diagnosis of personality disorder in adolescents by means of baseline and follow-up assessments of inpatients treated at the Yale Psychiatric Institute. METHOD: One hundred sixty-five hospitalized adolescents were reliably assessed by using a structured interview for personality disorder diagnoses as well as two measures of impairment and distress--the Global Assessment of Functioning Scale and the SCL-90-R. Two years after initial assessment, 101 subjects were independently reassessed with the same measures; their functioning was also assessed at this time. RESULTS: At baseline, adolescents with personality disorders were significantly more impaired than those without personality disorders. At follow-up, adolescents with a personality disorder diagnosis at baseline had used significantly more drugs and had required more inpatient treatment during the follow-up interval. Over time, the scores on the Global Assessment of Functioning Scale and SCL-90-R of adolescents diagnosed with a personality disorder at baseline became more similar to the scores of adolescents without a personality disorder. CONCLUSIONS: The diagnosis of personality disorder in adolescent inpatients has good concurrent validity; however, the predictive validity of the diagnosis is mixed.

Applicability of personality disorder criteria to hospitalized adolescents: evaluation of internal consistency and criterion overlap.

OBJECTIVE: The authors examined the applicability of personality disorder criteria to adolescent inpatients by evaluating internal consistency and criterion overlap. METHOD: Thirty-eight adolescents and 28 adults were assessed with the Personality Disorder Examination. Within-category cohesiveness (internal consistency) of the criteria was evaluated by examining intercriterion correlations as well as coefficient alpha. In addition, between-category criterion overlap was evaluated by examining "intercategory" intercriterion correlations between all pairs of disorders. Separate analyses were conducted for adolescents and adults, and the groups were compared. RESULTS: Internal consistency appeared to be lower in adolescents, as measured by intercriterion correlation and coefficient alpha, with the largest differences being identified for most cluster B disorders. Intercategory analysis indicated that criterion overlap may be greater among adolescents. CONCLUSIONS: Overall, this psychometric analysis suggests that there may be limitations to the DSMs approach to categorizing personality disorders. For both adolescents and adults, modest degrees of within-category cohesiveness (internal consistency) and between-category criterion overlap were observed. Comparatively, personality disorder criteria in adolescents tended to have lower internal consistency and less discriminant validity. The data raise questions about the construct validity of these disorders--or the applicability of these criteria--within this age group.

Frequency of personality disorders in two age cohorts of psychiatric inpatients.

OBJECTIVE: The authors examined the frequency of DSM-III-R personality disorders in adolescent and young adult psychiatric inpatients. METHOD: Structured diagnostic interviews were reliably performed with a series of 255 consecutively admitted inpatients (138 adolescents and 117 young adults). RESULTS: Most personality disorders were diagnosed in similar frequencies in the two study groups. Passive-aggressive personality disorder was diagnosed with lower frequency and dependent personality disorder with higher frequency in the young adult than in the adolescent group. CONCLUSIONS: The isomorphism of relative frequencies among psychiatric inpatients suggests that what is seen in adolescents are valid forms of most adult personality disorders.

Controlled study of psychiatric comorbidity in psychiatrically hospitalized young adults with substance use disorders.

OBJECTIVE: The purpose of this study was to examine DSM-III-R axis I and axis II comorbidity in psychiatrically hospitalized young adults with substance use disorders. METHOD: Structured diagnostic interviews were given to 117 consecutive inpatients. Seventy patients with substance use disorders and 47 patients without substance use disorders were compared. RESULTS: High rates of co-occurrence of axis I disorders were observed, but no disorder coexisted in the group with substance use disorders at a significantly higher rate than in the group without substance use disorders. Among axis II disorders, borderline personality disorder was diagnosed significantly more frequently in the group with substance use disorders. CONCLUSIONS: Significant additional diagnostic co-occurrence, defined as comorbidity, was observed only between borderline personality disorder and substance use disorders. The use of a relevant psychiatric comparison group allows for finer distinctions between covariation based on shared severity and comorbidity possibly based on shared pathophysiology.

Diagnostic comorbidity in hospitalized adolescents with conduct disorder.

We compared the diagnostic comorbidity of DSM-III-R axis I and axis II disorders in a sample of hospitalized adolescents with conduct disorder (CD) and a comparison group of hospitalized adolescents without conduct disorder (non-CD). Of 138 consecutively evaluated adolescents, 76 patients met criteria for CD and 62 did not. On axis I, CD was significantly comorbid with attention-deficit hyperactivity disorder (ADHD) and substance use disorders (SUDs). None of the personality disorders assessed showed differential association with CD. The comorbid relationships found within this sample suggest a strong association between CD, ADHD, and SUD in hospitalized teenagers. This finding underscores the clinical importance of conducting a thorough developmental assessment and, when indicated, of treating ADHD and SUD in conduct-disordered adolescents.

Psychiatric comorbidity differences in male and female adult psychiatric inpatients with substance use disorders.

To examine gender differences in the co-occurrence of DSM-III-R axis I disorders and axis II personality disorders in young adult psychiatric inpatients with substance use disorders (SUDs), a consecutive series of 70 inpatients (33 men and 37 women) with SUD were reliably assessed with structured diagnostic interviews. Higher rates of dysthymia and eating disorders were observed in SUD females and higher rates of cluster A personality disorders were observed in SUD males. No gender differences were found for depression or anxiety in our SUD inpatients; these findings contrast with gender ratios for these disorders in the general population. In conclusion, relatively few gender differences were found in young adult inpatients with SUD, even where they would be expected based on general population gender patterns.

Childhood trauma histories in adolescent inpatients.

The authors describe the prevalence of childhood traumatic experiences among adolescent inpatients. A Childhood Trauma Chart Review Scale (CTCRS) was developed to assess traumatic experiences during childhood and adolescence. The CTCRS was reliably applied to the medical records of 75 adolescent inpatients who had been given structured clinical interviews for DSM-III-R diagnoses at the time of admission. Most subjects (81%) had experienced at least one traumatic event during childhood, with loss of caregiver being the most frequent type of traumatic experience. Many subjects had multiple types of traumatic experiences, during both early and late childhood. A history of childhood trauma was associated with greater functional impairment and higher likelihood of having a personality disorder, but with no difference in Axis I diagnoses.

Personality disorders in adolescents with major depression, substance use disorders, and coexisting major depression and substance use disorders.

This study examined the presence of personality disorders in adolescent inpatients with major depression (MDD; n = 45), substance use disorders (SUD; n = 27), or both disorders combined (MDD-SUD; n = 42). A consecutive series of patients were given structured diagnostic interviews for Axes I and II disorders. The groups did not differ with regard to age, gender, ethnicity, socioeconomic status, psychiatric history, or global assessment of functioning. Borderline personality disorder was diagnosed more frequently in the MDD-SUD group than in the MDD or the SUD groups.

Gender differences in personality disorders in psychiatrically hospitalized young adults.

We examined gender differences in DSM-III-R personality disorders in psychiatrically hospitalized young adults. Structured diagnostic interviews were reliably performed on a consecutive series of 118 inpatients. Men were significantly more likely to meet criteria for cluster A, schizotypal, and antisocial personality disorders. To reduce variability due to axis I heterogeneity, we retested for gender differences in a subgroup of patients with major depression. Depressed men were more likely to meet criteria for cluster A, schizotypal, and cluster C personality disorders. Women were not observed to have a higher frequency of any personality disorder than men in either study group.

Gender differences in personality disorders in psychiatrically hospitalized adolescents.

OBJECTIVE: The authors examined gender differences in DSM-III-R personality disorders in adolescent psychiatric inpatients. METHODS: Structured diagnostic interviews were reliably performed with a series of 138 consecutively admitted adolescent inpatients. To reduce variability due to heterogeneity of axis I diagnoses, a subgroup of 87 patients with major depression was retested for gender differences. RESULTS: Females were significantly more likely than males to meet the criteria for borderline personality disorder. Narcissistic personality disorder was diagnosed only in males. A similar pattern was observed in the subgroup of patients with major depression. CONCLUSIONS: The findings suggest potentially important gender differences in personality disorders in adolescent inpatients.

Conduct disorder, substance use disorders, and coexisting conduct and substance use disorders in adolescent inpatients.

OBJECTIVE: The authors examined the association between conduct disorder and substance use disorders in adolescent inpatients. METHOD: Structured diagnostic interviews were given to 165 adolescent inpatients to assess the presence of DSM-III-R axis I disorders and personality disorders from axis II. Patients with conduct disorder (N = 25), substance use disorders (N = 24), and coexisting conduct and substance use disorders (N = 54) were compared to determine whether additional axis I and axis II disorders presented at significantly different rates. RESULTS: The groups with conduct disorder and coexisting conduct and substance use disorders had a higher proportion of male subjects than the group with substance use disorders alone. Patients with conduct disorder had an earlier age at first psychiatric contact and were diagnosed significantly more often with attention deficit hyperactivity disorder than the other two groups. Borderline personality disorder was diagnosed more frequently in the patients with substance use and coexisting conduct and substance use disorders than in the patients with conduct disorder. These differential co-occurrence patterns were observed for both male and female subjects. CONCLUSIONS: Conduct disorder and substance use disorders have high comorbidity rates with other psychiatric disorders in adolescent inpatients. The additional psychiatric comparison group (patients with coexisting conduct and substance use disorders) allowed for finer distinctions regarding psychiatric comorbidity. The validity of subtyping conduct disorder on the basis of the presence of a coexisting substance use disorder is suggested; conduct disorder patients without a coexisting substance use disorder are more likely to have attention deficit hyperactivity disorder.

Comorbidity of DSM-III-R axis I and II disorders among female inpatients with eating disorders.

Structured diagnostic interviews were used to determine DSM-III-R axis I and II diagnoses among 136 female psychiatric inpatients. To distinguish comorbidity of eating disorders with axis I and II disorders from simple diagnostic overlap, the frequency and distribution of diagnoses among the 31 patients with an eating disorder and the 105 without an eating disorder were compared. Social phobia, substance use disorders, borderline personality disorder, and avoidant personality disorder were diagnosed in a significantly larger proportion of the group with eating disorders. Future studies should focus on interpreting the meaning of the co-occurrence of these disorders in patients with eating disorders.

Psychiatric comorbidity in adolescent inpatients with substance use disorders.

OBJECTIVE: To assess DSM-III-R Axis I and Axis II co-occurrence and comorbidity in adolescent inpatients with substance use disorders (SUD). METHOD: A consecutive series of 138 adolescent inpatients were reliably assessed with structured diagnostic interviews for Axis I disorders and Axis II personality disorders. To determine significant co-occurrence of diagnoses, comparisons were between 69 patients with SUD and 69 patients without SUD. RESULTS: Disruptive behavior disorders were diagnosed significantly more frequently in patients with SUD than in those without SUD. Conduct disorder was diagnosed more frequently and oppositional defiant disorder was diagnosed less frequently in the SUD patients than in the non-SUD patients. Anxiety disorders were diagnosed less frequently in the SUD group. Cluster B personality disorders and borderline personality disorder were diagnosed more frequently in the SUD group. CONCLUSIONS: The findings replicate previous research showing high rates of co-occurrence of other psychiatric disorders in adolescent inpatients with SUD. The use of a relevant psychiatric comparison group allows for finer distinctions regarding significant comorbidity and the psychopathological implications thereof.